Annals of African Medicine
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Table of Contents
ORIGINAL ARTICLE
Year : 2014  |  Volume : 13  |  Issue : 4  |  Page : 195-203  

Pattern and outcome of admissions in the medical wards of a tertiary health center in a rural community of Ekiti state, Nigeria


Department of Internal Medicine, Federal Medical Centre, Ido-Ekiti, Ekiti State, Nigeria

Date of Web Publication7-Oct-2014

Correspondence Address:
Olarinde J Ogunmola
Consultant Physician and Cardiologist, Cardiac Care Centre, Department of Internal Medicine, Federal Medical Centre, Ido-Ekiti, Ekiti State
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/1596-3519.142291

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   Abstract 

Objective: To determine the pattern and outcome of medical admissions as well as the basic demographic characteristics in medical wards of a tertiary health center located in a rural area.
Materials and Methods : A retrospective analysis of medical wards admissions of the Federal Medical Centre, Ido-Ekiti, Ekiti State, southwest Nigeria, between January 2009 and December 2011. Data obtained was analyzed using SPSS Version 16 software.
Result: The total number of patients admitted during the period was 1519, age ranged from 16 to 120 years, with a mean of 56.1 + 18.8 years. There were 823 (54.3%) males and 696 (45.7%) females in a ratio of 1.2:1.0; the highest number of age group admitted was the elderly. Disorders of the cardiovascular system topped the admission list (32.1%) in general, and noncommunicable diseases were also predominant (68.4%) on the admission list compared with communicable diseases (31.6%). The most common cause of death was cardiovascular diseases (33.0%).
Conclusion: Male gender and elderly aged groups were predominant on admission. Noncommunicable diseases were of higher proportion on admission than communicable diseases. The most common cause of death was cardiovascular diseases of which stroke topped the list.

   Abstract in French 

Résumé
Objectif: Pour dιterminer le modθle et les rιsultats des admissions mιdicales ainsi que les caractιristiques dιmographiques de base dans les quartiers mιdicales d'un centre de soins tertiaires situι dans une zone rurale.
Matιriel et mιthodes: A une analyse rιtrospective de medical quartiers des admissions du Centre mιdical fιdιral, Ido-Ekiti, ιtat d'Ekiti, sud-ouest du Nigeria, entre janvier 2009 et dιcembre 2011. On a analysι les donnιes obtenues ΰ l'aide du logiciel SPSS Version 16.
Rιsultat: Total des patients hospitalisιs au cours de la pιriode, on comptait 1519, βge variait de 16 ΰ 120 ans, avec une moyenne de 56,1 + 18,8 ans. Il y a 823 (54,3 %) ιtaient des hommes et 696 (45,7 %) les femmes dans une proportion de 1.2:1.0 ; le plus grand nombre de groupe d'βge admis ιtait les personnes βgιes. Troubles du systθme cardio-vasculaire en tκte la liste d'admission (32,1 %) en gιnιral, et les maladies non transmissibles ont ιtι ιgalement prιdominant (68,4 %) sur la liste d'admission par rapport aux maladies transmissibles (31,6 %). La cause la plus frιquente de mortalitι ιtait les maladies cardiovasculaires (33,0 %).
Conclusion: Mβle entre les sexes et les groupes βgιs βgιes ιtaient prιdominantes sur l'admission. Les maladies non transmissibles ont une proportion plus ιlevιe sur l'admission que les maladies transmissibles. La cause la plus frιquente de mortalitι ιtait les maladies cardiovasculaires de quelle course en tκte de liste.
Mots-clιs: Nigeria, rιsultats pour les patients, la communautι rurale, centre de rιfιrence tertiaire

Keywords: Nigeria, patient outcome, rural community, tertiary referral center


How to cite this article:
Ogunmola OJ, Oladosu OY. Pattern and outcome of admissions in the medical wards of a tertiary health center in a rural community of Ekiti state, Nigeria. Ann Afr Med 2014;13:195-203

How to cite this URL:
Ogunmola OJ, Oladosu OY. Pattern and outcome of admissions in the medical wards of a tertiary health center in a rural community of Ekiti state, Nigeria. Ann Afr Med [serial online] 2014 [cited 2019 Jul 23];13:195-203. Available from: http://www.annalsafrmed.org/text.asp?2014/13/4/195/142291


   Introduction Top


The most common cause of deaths in adults are medical conditions. [1] Africa bears nearly a quarter of the world's burden of diseases. [2] The health of adults in sub-Saharan Africa is becoming an increasingly important priority in global health policy. [3],[4] Recent study showed that levels of adult mortality (deaths between the ages of 15 and 60 years) are 4-40 times more in the sub-Saharan Africa than in the developed countries. [5],[6],[7],[8],[9] Studies in rural centers in Nigeria have also revealed that most deaths occur in adults in their prime of life. [10],[11] The World Health Organization (WHO) predicts that by 2020, the causes of disease and deaths in sub-Saharan Africa would have undergone a significant shift from communicable to noncommunicable diseases (NCDs). [12] This shift will necessitate changes in health policy and deployment of health resources to deal with new challenges. [13],[14]

Furthermore, recent improvement in the survival of children [5],[8],[15] means that the proportion of population, which is increasing, beginning with the young adults requires sustenance. [16] The pattern of illnesses responsible for the high mortality among adults in sub-Saharan Africa has not been well characterized. [4],[7],[8],[9],[17],[18] The survival of children is closely linked to that of adults and to maintain the gains made in reducing child mortality, the pattern and outcome of adult diseases need to be identified. Few related studies were conducted in urban centers in Nigeria, which obviously left out the majority of the populace that resides in rural areas. Therefore, this study aimed to determine the pattern and various outcomes of medical admissions as well as the basic demographic characteristics in a tertiary health center situated in a rural area.


   Materials and Methods Top


A 3-year retrospective analysis was conducted on records of patients admitted in the male and female medical wards of the department of Internal Medicine, Federal Medical Centre Ido-Ekiti, Ekiti State, southwest Nigeria. This hospital functions as a teaching hospital to Afe Babalola University in Ado-Ekiti. It is a leading referral tertiary health center located in a rural community of Ido-Ekiti. The community is about 30 km from Ado Ekiti, the state capital. The hospital serves a population of 2.4 million people of Ekiti State in addition to a unestimated population from neighboring states. This retrospective review included patients admitted in medical wards that had complete information and met the standard clinical and/or laboratory diagnostic criteria. The period of study was from January 2009 to December 2011. The study population included patients who were aged 16 years and more. We excluded patients whose data were not complete or those aged less than 16 years. Records available in the wards (nurses report books), and case notes from the medical records department were all utilized. All the diagnoses were based on the final diagnoses made by the supervising consultants. These were arrived at on combination of clinical and laboratory parameters of patients. In addition, Widal test and blood culture were included in the diagnosis of typhoid cases. Viral encephalitis was diagnosed on clinical, cerebrospinal fluid analysis (no viral study was done). Three cases selected underwent electroencephalography among other supporting general investigations. Nineteen patients (10%) with stroke had cranial computerized tomography (CT) done due to nonaffordability and nonavailability of CT scan in the center. However, the WHO criterion, which has been shown to have a high sensitivity among Nigerians, was used to determine the pathological stroke type. [19] Echocardiography among other basic investigations was performed on 100 (49.8%) of heart failure patients due to nonaffordability. However, Framingham clinical diagnostic criteria, which have been widely used and validated, were applied to all cases of heart failure patients included. [20] All chronic liver disease patients studied had abdominal ultrasound done, only four patients (11.8%) had liver biopsy results. Upper gastrointestinal endoscopy was done for four patients (26.7%) with evidence of upper gastrointestinal bleeding, which was also due to nonaffordability and nonavailability. Eight patients (72.7%) with hematological malignancies had either bone marrow aspiration or biopsy done apart from blood analysis. Forty-two patients (73.7%) with chronic obstructive pulmonary disease had lung function test done while all had chest X-ray done.

We designed a data extraction form and entered the data from each patient record into the form, which was later cross-checked for accuracy. The following data were collected from each patient: Age, gender, cause of admission, definitive diagnosis, outcome during admission, year of admission, and clinical cause of patient's death (if death occurred). The diseases diagnosed were grouped into body systems according to the WHO International Classification of Diseases 10 th version (ICD-10) guidelines. [21]

In this study, the outcome was defined as follows: Discharged, died, referred, and discharge against medical advice (DAMA). Ethics and research committee approval from the institution was obtained. Data obtained were analyzed using the Statistical Packaging for Social Sciences (SPSS Inc. Chicago IL) SPSS Version 16 software and the results are presented in the descriptive and tabular forms.


   Results Top


The total number of patients admitted in the medical wards during the study period was 1519, of which males and females constituted 823 (54.2%) and 696 (45.8%), respectively [Table 1]. The male to female ratio of 1.2:1.0 revealed that there were more male patients admitted than female patients. The minimum age of patients that were admitted was 16 years while the maximum age was 120 years, with a mean age of 56.1 + 18.8 years. The age range for males was 16-120 years with a mean age of 56.0 + 18.8 years while the range for females was 16-98 years with a mean age of 56.2 + 18.8 years. [Table 2] shows that the highest number of admissions were the elderly, 616 (40.6%), followed by the middle-aged group, 472 (31.1%), and then the young-aged group, 431 (28.4%). In [Table 3], the most common cause of medical admissions was cardiovascular disorders, 488 (32.1%). Toxins and poisons as well as dermatology cases were uncommon (0.7% and 0.4%), while rheumatology cases were relatively rare (0.3%).
Table 1: Medical wards admissions between January 2009 and December 2011

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Table 2: Age and sex distribution of medical wards admission between January 2009 and December 2011

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Table 3:

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In [Table 4], the outcome of medical admissions showed that 179 patients (12.3%) died, 97 patients (6.4%) DAMA, 69 patients (4.5%) were referred to relevant centers, and 1174 patients (77.3%) were discharged home. The most common causes of deaths in this study were NCDs (63.1%), of which cardiovascular diseases (CVDs) were mostly responsible, 59 (33.0%), and stroke topped the list accounting for 22.3% causes of all deaths. Six out of eight deaths in patients with diabetic foot ulcer resulted from septic shock, while two others died from acute kidney injury from severe sepsis. One death from urinary tract infection resulted from severe sepsis.
Table 4: Outcome of medical admissions in the medical wards between January 2009 and December 2011

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   Discussion Top


Disease patterns seen in the medical wards generally will mirror the pattern of medical disorders in the geographical environment the hospital subserves. Within the period of study, the higher male to female ratio, which was consistent for the 3 years reviewed, suggests that male frequently suffered medical conditions more than females. In Africa generally (including Nigeria) men are the bread winners of their family. Therefore, men are more involved in daily exploration of their environment to earn reasonable income. Subsistence farming and hunting with crude implements are major occupation of rural dwellers, which involved men than women. Hence, men are more endangered and overworked. The nature of these jobs no doubt will have a negative effect on their health compared with women who engage in petty trading and domestic work. However, male gender is associated with some social traits such as tobacco use and excessive alcohol consumption. These are identified risk factors for NCD and might have contributed to the higher prevalence of NCD in males as seen in this study. Unpublished observation has shown that higher female populations are seen in religious houses for spiritual interventions and healing compared with males. This may affect the population of women patronizing orthodox care. There is also possibility of female hormone (estrogen) protection especially against CVDs. This finding of male preponderance in hospital attendance was similar to previous findings in urban and suburban studies in the past. [22],[23],[24],[25],[26],[27] It is not impossible that males may have better health seeking behavior than females. This in turn may contribute to the findings in this study.

The highest proportion of patients admitted were the elderly (aged 60 or more) compared with middle-aged and young adult-aged groups. This observation may be due to frailty and ageing, which relatively reduce body immunity and therefore disease susceptibility. Also strong cultural beliefs for the care of the elderly in southwest Nigeria might have also influenced hospital care. The increased risk for CVD with ageing may also account for more elderly on admission compared with other age groups. This similar observation of elderly dominance in medical wards admissions has been documented in the urban center, Nigeria. [28] However, studies had shown that developing world is experiencing an aging population with its attendant increase in the burden of chronic diseases. [29] It is projected that the total geriatric population (aged 60 or more) worldwide will rise from 605 million in the year 2002 to1.2 billion in 2025. [30] Similarly, it has been reported that the population of elderly persons may double in sub-Saharan Africa between 2000 and 2030. [29] Findings in other parts of Africa and other continents of the world on medical ward admissions showed that elderly predominate. [31],[32],[33]

Public health planning in most developing countries has focused mainly on problems related to communicable diseases that have in the past been responsible for most morbidity and mortality. [34],[35] This situation is different in more developed countries such as the United States, where coronary artery disease (CAD) is the leading cause of death. [36] However, chronic and degenerative diseases such as CAD are making an increasingly important contribution to the mortality statistics of countries such as Brazil, Chile, Cuba, Argentina, and Costa Rica. [36] It was observed in this study that NCDs were the major reasons for medical wards admissions compared with communicable diseases. This finding is in agreement with recent studies in urban and suburban centers in Nigeria and elsewhere. [24],[25],[26],[37] This observation of continuous but consistent transition towards endemicity of NCD may be due to increasing adoption of westernized life style, reduced physical activity, increasing obesity, and urbanization. Recent drift away from communicable diseases towards NCD in this report may be due to improved personal hygiene and environmental sanitation, which has been a monthly wake up calls in most states in southwestern Nigeria. Similarly, widespread awareness and administration of vaccines and supplements might have contributed. It should be noted that CVDs were the most common reason for admission of all the NCDs. This basically rested on the increased prevalence of cardiovascular risk factors since many of our patients had hypertension, diabetes mellitus, and are aged. Most of the patients had systemic arterial hypertension as the etiological factor for heart failure, stroke, and chronic kidney diseases. Systemic arterial hypertension is the most common cardiovascular risk factor, which is been previously documented. [38] The recent WHO report [1] showed that CVD is a leading contributor to global disease burden. In addition, NCDs are the leading killers today and are on the increase. [1] Nearly 80% of these deaths occurred in low- and middle-income countries. [1] The leading cause of admission in NCDs was heart failure.

The most common disorder of the respiratory system was chronic obstructive pulmonary disease. This is probably due to chronic exposure to smoke through indoor pollution from cooking with firewood and dust through farming activities. Tobacco use is not uncommon among rural dwellers, which may also contribute to this finding. Tobacco use may be related to aggressive marketing by tobacco companies; delay in implementing antismoking regulations, and the public perception that the risk of smoking is still low. [39]

The predominance of chronic renal failure among renal disorders in this study was probably due to the increasing prevalence of hypertension and diabetes. In addition, exposure to nephrotoxic herbal agents and indiscriminate use of over the counter drugs (analgesics) in the rural setting may also contribute.

The small proportions of rheumatology and dermatology cases were probably because specialist in those areas were not available in the hospital, and therefore, patients with those conditions were not being referred to the center and few that get to the accident and emergency unit were probably referred. Toxins and poisons were relatively uncommon reasons for medical admissions, as observed in this study. Intentional self-poisoning is common in many parts of the world. [40],[41] However, its case-fatality ratio (CFR) differs markedly between industrialized and developing worlds. [42] In every 1000 self-poisoning patients admitted to European hospitals, fewer than 5 die, [43] and for every 1000 admitted to rural Asian hospitals, 100-200 die. [40] In this study, few patients were seen and no fatality was recorded. This observation may be related to the existence of the psychiatry department in the hospital. The department frequently received patients with intentional poison. Furthermore, some of these patients might have been treated in the secondary health center and therefore not referred, or discharged after treatment in the accident and emergency unit. The findings in this study may also be related to the religious nature of Nigerians, since religious faith is against suicide. In addition, low level of industrialization of the environment might further reduce exposure of individuals to chemicals and therefore, low incidence of accidental poison. Commonly encountered toxins and poisons include rat poison, kerosene, paraquat insecticides, powdery content of lead battery, and battery acid.

The most common causes of deaths in this study were NCDs of which CVDs were mostly responsible and stroke topped the list [Table 5]. This was reported in one of our study presently in the press. The Global Burden of Disease has estimated that cerebrovascular disease (that corresponds to stroke, in this paper) is the second most common cause of death in the world. This contributed 9.5% of mortality in low- and middle-income countries and 9.9% in high income countries. [44] In nearly all the developed countries, stroke mortality had decreased between 1950 and 2005, often very considerably. [45] In many countries it had reduced by 50% or more; in Japan by 85%. [45] Decline was continuous from 1950 in the USA, Canada, UK, Sweden, Denmark, Finland, Italy, Australia, and (from 1980) in Hong Kong. [45] In another study from a group of countries, mortality did not change until it decreased in the early 1970s namely Ireland, Norway, Spain, Chile, New Zealand, and (from 1963) in Singapore. [45] In several of the first group of countries, a faster decline in mortality was seen in the 1970s. [45] The large variation in stroke mortality worldwide is likely to be due to differences in environmental factors apart from genetic influence. [46] In the Black population, contribution of high salt intake to the development of hypertension has been documented. [47] Similarly, in our environment, hypertension has been reported as the leading risk factor for stroke and poor control of hypertension was also observed. [22],[23],[24],[25] Studies have shown that the reduction in stroke mortality in Japan was much greater than that in any other country, which started in 1965. There are reports of a large reduction in salt intake in Japan. [48] Salt (NaCl) intake in Japan reduced from 360 mmol/day in 1950 to 187 mmol/day in 1988. [48] Similarly, in the Belgium men, the prevalence of systolic blood pressure above 159 mmHg decreased from 51% to 21% between 1967 and 1986. [49] Mean systolic blood pressure decreased from 159 to 142 mmHg and the proportion of subjects receiving treatment for hypertension increased from 10% to 36%. [49] Mean standardized 24 h sodium excretion decreased from 265 to 188 mmol. The decrease in stroke mortality in Belgium was related to the combined effects of treatment for hypertension and a decrease in sodium intake. [49] This is in contrast with Portugal, where the diet is traditionally very rich in salt. [50] Although the salt content of the Portuguese diet has been declining in recent decades, Portugal still has the highest rates of stroke mortality in Western Europe. [50] Higher rates of stroke in lower socioeconomic groups and in rural areas suggest a link between stroke mortality and adherence to the traditional Portuguese diet. [50] Therefore, in this study, poor control of systemic arterial hypertension, high rates of cardiovascular risk factors, clustering of risk factors, increased prevalence of CVD, and late presentation or referral may all be responsible for CVD as the leading causes of deaths. Similar findings have been previously documented in urban centers. [7],[8],[24],[25],[28] Furthermore lack of access to early CT scan, unavailable fibrinolytic agents, and lack of early recognition may all contribute to high mortality in stroke. In addition, lack of integration of public health education, emergency dispatch and triage, hospital stroke system development, stroke unit management, creation of stroke centers, and establishment of effective rapid response team may all contribute to high mortality.
Table 5: Causes of patients' deaths in medical Wards between January 2009 and December 2011.

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In spite of the global efforts against the Human Immunodeficiency Virus and Acquired Immune Deficiency Syndrome [HIV/AIDS] pandemic, this study showed that HIV/AIDS was the leading cause of deaths of communicable diseases. Similar finding have been documented in urban centers. [24] This may be due to late presentation of patients from various reasons like local beliefs of possible cure from the use of local herbs, possibility of spiritual healing, poverty, and ignorance. Stigma and discrimination remain high and continue to be a barrier for accessing services. People living with HIV are also frequently coinfected with other diseases such as tuberculosis, sexually transmitted diseases, viral hepatitis, malarial fever and others, which complicate diagnostic and treatment interventions. Sepsis ranked the second cause of deaths among communicable diseases, in which poor access to quality healthcare due to poverty and delay presentation may account for it. This was unlike findings in urban centers by Odenigbo and Oguejiofor, [24] where severe malaria ranked second cause of deaths in the medical ward admission.

The proportion of patients discharged home (76.7%) coupled with those that were referred (4.5%) showed the high quality of services available in the hospital. However, the proportion of those that were lost to deaths (12.3%) and DAMA (6.5%) showed that a lot needs to be done particularly in the area of early presentation, health education, reduction of poverty, improvement on access to healthcare services, engaging a wide variety of strategies to finance and organize services. DAMAs most time were observed to be due to poverty, sometimes wrong cultural or religious beliefs or tracing of causes of illness to spiritual attacks.

Our study is not without limitation. Inherent limitations found in retrospective study such as incomplete medical record keeping, missing data, lack of some essential information, and under reporting existed in this study. In addition, lack of postmortem evidence on deaths as well as possible diagnostic error in those patients without gold standard instrument of diagnosis also serves as limitation.


   Conclusion Top


This study reports that there were higher proportions of males admitted in the medical wards than that of females. The proportion of patients admitted increased with increasing age groups in which the elderly patients formed the highest proportion. NCDs particularly CVDs were the most common causes of admission of which heart failure caused by systemic arterial hypertension topped the list. The major cause of death was CVDs, principally stroke. The leading cause of deaths from communicable diseases was HIV/AIDS followed by sepsis. Possible key ingredients of success may include concerted efforts to reach the poor, engaging local adaptation that may be of benefit, and more importantly prevention of cardiovascular risk factors and further evaluation of HIV/AIDS care.



 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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